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Do you know someone with pelvic organ prolapse (POP)? Chances are you do, or you may be suffering from symptoms of this condition yourself, without knowing the cause. Though estimates of percentage of sufferers vary from study to study, the UChicagoMedicine website says POP "is very common, with about 50 percent of women having some degree of prolapse. Over 12 percent of American women will have surgery for it in their lifetime." In the UK, "loss of vaginal or uterine support is seen in up to 30-76% of women presenting for routine gynecological care" (Barber 2016). The Association for Pelvic Organ Proplapse Support (APOPS) accepts 50% as a workable estimate, though it acknowledges we don't have accurate figures yet. 

What is Pelvic Organ Prolapse?

Pelvic organ prolapses (POP) are anatomical displacements largely caused by weakening of pelvic support structures--muscles and ligaments--causing organs to bulge against the vaginal wall, similar to a hernia. Though POP is usually associated with (older) cis-women who have given vaginal birth, any adult with a vagina, uterus, rectum, and bladder can experience some form of POP. Uterine prolapse, rectocele (rectal prolapse), and cystocele (bladder prolapse) can manifest singly, or in combination, and there are various degrees of severity. In some cases, the uterus may descend completely outside the body, causing a medical emergency. Most common risk factors are giving "vaginal childbirth, advancing age, increasing body mass index, and prior hysterectomy" (Barber 2016). Certain medical conditions, such as Ehlers-Danlos Syndrome, also increase the risk.

In addition to organs bulging at the entrance of the vagina, symptoms may include pelvic pain and painful vaginal intercourse (dyspareunia), diminished sexual function and enjoyment, urinary incontinence, fecal incontinence, chronic constipation, and quality of life issues associated with these symptoms. Some people are asymptomatic, however, and may go years without realizing they are experiencing organ prolapses until their condition has worsened and surgery becomes inevitable. Standing digital pelvic exams are more useful than the usual "feet in the stirrups" exams for obtaining an accurate diagnosis of prolapse (podcast interview with Sherrie Palm, founder of APOPS, Oct. 17, 2019). 

Treatments

Treatments include Pelvic Floor Therapy (PFT) (especially great if you are diagnosed early), pessaries (devices worn inside the vagina to hold organs in place), and various forms of surgery--even including colpocleisis, (which surgically closes the interior of the vagina, not by sewing the labia), classed as an obliterative surgery. Colpocleisis has a 90-95% success rate but is mostly reserved for elderly women, in spite of a demand from some younger patients. Restorative surgeries are more common, though failure rates are higher and some people need to undergo surgeries several times. Hysterectomies may also be done to treat a uterine prolapse, however this may then cause displacement of the other pelvic organs. 

You can find more information at APOPS (Association for Pelvic Organ Prolapse Support) and Voices for PFD (Pelvic Floor Disorder).
Links to a PDF list of an array of POP studies--including those concerning sexual issues and POP--can be found at POP page on my website.

Counseling

At first glance, the complex medical and surgical aspects of pelvic organ prolapse may seem daunting to a sexualty counselor who is not a medical professional. However, just as counseling is offered to clients who have other kinds of sexual problems co-morbid with a medical condition (e.g. a man who experiences erectile dysfunction and also has a diagnosis of diabetes, afflicting circulation or a woman with vaginismus who is pregnant), counseling for people with POP can be offered within the "PLISS" portion of the PLISSIT model for sexuality counseling (Annon 1976). PLISS stands for "permission, limited information, specific suggestions" ("IT" stands for intensive therapy and should only be offered by those with specific credentials). 

Opportunities for counseling include addressing issues of shame, anger, guilt, frustration, and sadness experienced in conjunction with this condition as well as diminished quality of life; adult "sex ed" for intimacy and sexual enrichment options beyond P/V intercourse; encouragement and empowerment regarding medical treatments or compliance with PFT exercise regimens, and so on. Partners may range from supportive to unsympathetic or worse. A client with POP may need assistance with one, some, or all of the above.

For example, a client with a rectocele may have a great deal of shame about having to "splint"--the process of inserting a finger into the vagina to push against the rectocele-- which is like a "pocket"--in order to evacuate a stool. And this person may also have shame about periodic urinary and/or rectal incontinence. Shame, frustration, anger, and sadness may also result because the client also has a prolapsed uterus and cystocele, and their partner has expressed disgust at the client's organs bulging at the entrance of the vagina, and has refused to engage in giving oral sex, which they previously both enjoyed. Without the partner's support, the client feels too discouraged to do the daily routine of exercises recommended by a pelvic floor therapist, because "what's the point?"

Variations on the above scenario abound. You could also add counseling to address feelings due to loss of employment, as some prolapses become severe enough to interfere with work, particularly work that involves lifting heavy objects or standing for long hours (disability insurance is seldom approved for this condition). Or the client may have a restricted recreational and social life, as some activities become difficult due to incontinence or pain.

Lack of Professional and Public Awareness

Unfortunately, many kinds of medical and mental health professionals are vastly unaware and under-educated about POP, and that includes human sexuality professionals. I recently searched through the indexes of most of my human sexuality books (sex therapy books, college level sex ed textbooks, sexuality self-help books, etc., even the classic Kinsey and Masters & Johnson books). Most books contain very little information and what is there it is piecemeal and incomplete. Usually the indexes might mention a symptom such as urinary incontinence or painful intercourse, but without mentioning a possible or probable association with prolapses. Specific references to POP impacts on sexual function and pleasure are even scarcer.

Aside from client/patient reluctance to mention the embarassing symptoms of POP, and the lack of professional training and knowledge across the spectrum of medical and mental health care providers, I believe the "invisibility" of POP is also related to devalued or marginalized people (aging, female, other gendered) and groups (there's potentially a long list here). As counselors, we hope to nurture resilience, knowledge, and empowerment for our clients, but in this case, most of us aren't even aware of this widespread condition. So how can we hope to support our clients who may be dealing with POP, in silence, pain, frustration, and shame?

There is a tremendous opportunity here to get up to speed on POP and to bring this into our sexual wellness work. The published Pelvic Organ Prolapse/Urinary Incontinence Questionnaire--short form PISQ-12 and long form PISQ-32--(Rogers et al, 2001, 2003) can be incorporated into our sexual history questionnaires or other assessments. An article about the PISQ-12 is attached.

I urge all those working in the area of sexual health and wellness to put pelvic organ prolapses on your radar now!

Journal References

Annon JS. The PLISSIT Model: A Proposed Conceptual Scheme for the Behavioral Treatment of Sexual Problems, Journal of Sex Education and Therapy, 1976, 2:1, 1-15, DOI: 10.1080/01614576.1976.11074483

Barber MD. Pelvic Organ Prolapse. BMJ 2016 : 354 doi: https://doi.org/10.1136/bmj.i3853

Rogers RG, Coates KW, Kammerer-Doak D, Khalsa S, Qualls C. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct. 2003 Aug;14(3):164-8; discussion 168. Epub 2003 Jul 25.